MEDICARE: LINDA I GIBBENS ATC, LAT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2255A2300X	Athletic Trainer	2255A2300X	ID

General Provider Information

NPI Number	:	1730217225
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LINDA I GIBBENS ATC, LAT

Provider Business Mailing Address
First Line	:	902 LINFIELD PL
Second Line	:
City	:	CALDWELL
State	:	ID
Zip	:	83605-5197
Country	:	US
Telephone Number	:	208-454-8001
Fax Number	:	208-454-8001

Provider Business Practice Location Address
First Line	:	2112 CLEVELAND BLVD
Second Line	:
City	:	CALDWELL
State	:	ID
Zip	:	83605-4432
Country	:	US
Telephone Number	:	208-459-5873
Fax Number	:	208-459-5854

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/28/2007
Last Update Date	:	07/08/2007

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